Management of human resources associated with misuse
of prescription drugs: analysis of a national survey.

Abstract:

Nonmedical use of prescription drugs is increasingly prevalent in
the United States, but limited research is available on prescription
drugs misuse in the workforce. We investigated whether absenteeism and
turnover are associated with having problems linked to prescription drug
misuse among employees. We also further explored the moderating effects
of employee drug policy and testing on the relation between having
problems linked to misuse of prescription pain relievers (PPRs) and
absenteeism and turnover. This is a crosssectional study (n=2,249) using
the 2007 U.S. national survey data ("National Survey on Drug Use
and Health"). The multivariate logistic analysis results
illustrate, after controlling confounding factors (gender, age, tobacco
use, and heroin use), absenteeism and turnover linked to having problems
of PPRs misuse. Our findings suggest the moderating effects of employee
drug policy on the association between absenteeism and turnover and
having problems linked to misuse of PPRs. Also, drug testing was found
to moderate the link between having negative outcomes of misuse of PPRs
and absenteeism. Having problems associated with misuse of PPRs is
linked to absenteeism and turnover. A drug policy program including drug
testing may play a significant role in reducing absenteeism and turnover
in relation to having problems linked to misuse of PPRs.

Prescription drug abuse or misuse has been a strong public health
concern in recent years (Compton & Volkow, 2006). In 2006, about 48
million Americans had misused prescription drugs in their lifetime
(NIDA, 2006) and about 7 million Americans are current nonmedical users
of prescription drugs (NIDA, 2008). The estimated number of emergency
department visits for nonmedical use of opioid analgesics increased 111%
during 2004-2008 (from 144,600 to 305,900 visits) (CDC, 2010). As recent
literature continues to document prescription drug misuse problems among
many Americans (CDC, 2010; Kroutil et al., 2006; Simoni-Wastila et al,
2004; Manchikanti, 2007;

Matzger & Weisner, 2007; McCabe et al, 2009; Fenton et al.,
2010), it is necessary to further expand research of prescription drug
abuse or misuse in the American workforce.

There are a host of recent studies largely focused on prescription
drug problem among the general public (CDC, 2010; Kroutil et al., 2006;
Simoni-Wastila et al, 2004; Manchikanti, 2007; Matzger & Weisner,
2007; McCabe et al, 2009; Fenton et al., 2010), but inadequate attention
has been focused on employees' prescription drug use problems,
although about 7% of the American labor force reported using
prescription drugs nonmedically in the year prior to the survey (NIDA,
2008). A recent national estimate suggests (SAMHSA, 2007) that nearly
75% of illicit drug users aged 18 or older were employed either
full-time or part-time. The same report indicates that approximately 17%
of unemployed were current illicit drug users, while 8.2% of full-time
employed and 11% of part-time employed were current illicit drug users.
A considerable number of studies document alcohol and illicit drug use
problems in the workforce (French et al., 1995; Matano et al., 2002;
Roberts & Fallon, 2001; Frone, 2006a;

Understanding employee absenteeism and job turnover linked to
prescription drug misuse is important in the context of human resource
management for at least two reasons. First, organizations are by and
large concerned about the quality of human capital; in particular
employees' risky behaviors because those risk behaviors diminish
performance (Serxner et al., 2001) and increase injury or accidents in
the workplace (Spicer et al., 2003). Prior research supports the
association between work performance and alcohol and illicit drug use
(French et al., 1995; Mangione et al., 1999; Bass et al., 1996; Normand
et al., 1990). Surveying 1,200 employees at five different worksites,
French et al. (1995) reveals the association between illicit drug uses
including prescription drug misuse and reduced performance and
absenteeism. A recent national survey report (SAMHSA, 2007) also
suggests that drug using employees, compared to their non-drug-using
counterparts, had higher job turnover, missed work more than 2 days
because of illness and injury, and skipped work for more than 2 days in
the past month. A recent Substance Abuse and Mental Health Services
Administration (SAMHSA) report confirms prescription drug abusing
employees missing more than 2.2 days of work monthly when compared to
the 0.83 days monthly for the average person(US DHHS, 2008; Ruetsch,
2010). Second, in addition to workplace performance issue, employers may
experience financial difficulty of providing excessive healthcare
coverage to those drug using employees (Harwood et al., 1998). Substance
abuse problems in the workforce cost American firms billions of dollars
each year (SAMHSA, 2009) and evidence suggests associations between
employees' substance misuse and costs (US DHHS, 1999). Rising
health care spending makes many American firms less competitive in the
global marketplace (US DHHS, 2004; Porter, 2004) and employees'
risk behaviors negatively benefit competitive advantages of a firm in
the current economic downturn market.

Notwithstanding acknowledgement and the importance of substance
abuse problem in the workforce, understanding nonmedical use of
prescription drugs linked to employment factors has been largely
unnoticed. The objective of this research is thereby (1) to explore the
association of employment factors (absenteeism and turnover) with
related problems of PPRs, (2) to investigate the moderating effects of
employee drug policy/testing on the relation between having problems
associated with misuse of PPRs and absenteeism/turnover.

METHODS

Data Source

The present study uses a 2007 National Survey on Drug Use and
Health (NSDUH) (formerly known as National Household Survey on Drug
Abuse) to examine employment factors associated with related outcomes of
PPRs among the employed. NSDUH is a nationally representative annual
survey conducted by SAMHSA, and it was designed to measure the
prevalence and correlates of drug uses among members of the U.S.
households aged 12 and older (SAMHSA, 2007). The survey was done using a
combination of computer-assisted personal interviewing (CAPI) conducted
by an interviewer and audio computer-assisted self-interviewing (ACASI).
This survey takes about one hour to complete and employed a 50-State
design with an independent, multistage area probability sample for each
of the 50 States and the District of Columbia. Each participant received
a monetary incentive of $30 in an effort to increase response rates. The
study yielded a weighted screening response rate of 89.5 percent and a
weighted interview response rate for the Computer Assisted Interview
(CAI) of 73.9 percent. More detailed information about the NSDUH methods
and study design is available elsewhere (SAMHSA, 2007).

For the purpose of the study, of the total surveyed samples (n=
55,435), only employed individuals who misused prescription pain
relievers in the past year (n=2,249) were included in the analysis
(Figure 1). Of the sample (n=2,249), 59.03% were male and 75.46% were
non-Hispanic whites. About 34% were young adults (in the age range of
18-25), and nearly 40% were 35 years old or older.

[FIGURE 1 OMITTED]

Measure

Dependent variable. Having problems associated with misuse of
prescription pain relievers (PPRs) was used as dependent variable.
Specifically participants were asked, "During the past 12 months,
did using prescription pain relievers cause you to have serious problems
(neglecting children, missing work or school, doing a poor job at work
or school, and losing a job or dropping out of school) either at home,
work, or school." The response was categorical (yes=1, no=0).
Misuse of PPRs refers to use of any form of prescription pain relievers
that were not prescribed for themselves or that they took only for the
experience or fee ling they caused.

Covariant variables. Every participant was asked about demographic
characteristics including age (3 categories: 18-25, 26-35, >35),
gender (male/female), race/ethnicity (Whites, Blacks, Asians,
Hispanics), education (4 categories: 500); (4) job
turnover ("How many different employers, including yourself, have
you had in the past 12 months?") (4 categories: 1, 2, 3, 4 or more
jobs); and (5) work absent ("During the past 30 days, that is from
up to and including today, how many whole days of work did you miss
because you did not want to be there?) (Continuous response: 1-30 days).
Individual risk behaviors (tobacco/alcohol/heroin use) were also
measured (self-report uses in the past year) (yes or no).

ANALYSES

Mean scores (s.d.) of all dependent and covariant variables were
first generated and then the binary analysis of the sample by employment
status was conducted. We also undertook the hierarchical logistic
regression analysis to test how employment-related variables hold their
significance in relation to related problems of PPRs misuse while
controlling for other confounding variables. In Model 1, workplace
variables such as employment status, workplace size and drug
policy/testing were forced into the equation to test the bivariate
association with having problems of PPRs misuse. In Model 2, absenteeism
and turnover were added to the association with the dependent variable.
Interaction terms were added to Model 3 to test the joint effect of two
variables (drug policy/testing and absenteeism/turnover) on causing
problems of PPRs misuse. Model 4 controlled for demographic variables
(gender, age, race/ethnicity, and education) as well as personal risk
behaviors (tobacco/alcohol/heroin uses in the past year) that were
forced into the equation to test its association with having problems of
PPRs misuse. Fstatistics were reported in the regression, instead of
rsquared. The pseudo r-squared is not applicable to complex survey
design data as we already correctly specified and distributed the
sampling weights. STATA 10.1 (Stata Corporation, 2007) was used for all
analyses. Correctly generating national estimates is critical when
analyzing data with complex survey design and hence sampling weights
were all applied using survey commands (svy) in STATA.

RESULTS

Mean scores and its standard deviations of all measured variables
in the analysis are presented in Table 1.

Table 3 displays the multivariate logistic regression analysis
results. In the first two models, workplace drug policy was significant
but did not remain significant in the last two models while controlling
for personal confounding factors, suggesting that personal factors play
a role affecting having problems associated with misuse of PPRs.
Absenteeism ([beta] = .74, p= .004) and turnover ([beta] = 1.07, p= .04)
remained significant while controlling for personal factors, suggesting
that individuals having PPRs related problems are more likely to
experience absenteeism and turnover. Workplace drug policy was found to
interact with turnover ([beta] = .03, p= .006) and absenteeism ([beta] =
-.71, p= .049) in relation to having negative impact of misuse of PPRs,
suggesting the use of drug policy may increase absenteeism but reduce
the job turnover rate. Drug testing was also found to be interacted with
absenteeism ([beta] = - .39, p= .002), suggesting that drug testing may
reduce absenteeism in relation to having problems of prescription drug
misuse. Of personal confounding factors added to Model 4, only heroin
use in the past year ([beta] =1.51, p= .025) was found to be associated
with having problems caused by misuse of PPRs. This suggests that heroin
using employees are more likely to face some problems linked to misuse
of PPRs.

DISCUSSION

The current literature lacks evidence of the association between
prescription drug misuse and employment factors in the American
workforce. Our study offers an important contribution to the literature
by revealing some problems associated with misuse of PPRs linked to
absenteeism and turnover after controlling for personal factors, which
is in line with prior research (French et al, 1995; SAMHSA, 2010) that
substance abusing workers, compared with their non-substance abusing
counterparts, are more likely to change jobs frequently and to be late
to or absent from work. Prior research inadequately has examined the
possible moderating roles of employee drug policy/testing in relation to
having problems of misuse of PPRs. Our analysis adequately fills this
research gap. Our finding that drug policy increases absenteeism in
relation to having problems associated with misuse of PPRs is at odds
with another finding that drug policy moderates the association between
job turnover and facing problems related to misuse of PPRs. It is
uncertain why the same policy variable produces dissimilar effects but
no related research exists. One possible explanation would be that a
comprehensive drug policy program including drug testing may motivate
employees to be absent in order to avoid getting caught if they still
have drugs in their system. So, employees may choose absenteeism over
turnover after being exposed to drugs, which may lead to less employee
turnover. Future study might want to take a further step to investigate
this research question. Our study also found the moderating effect of
employee drug testing on the link between absenteeism and having some
problems associated with misuse of PPRs, suggesting that employees with
PPRs-related problems are less likely to experience absenteeism if drug
testing is in place. This finding may be comparable to prior studies
that drug testing may benefit workplace performance in reducing
absenteeism (Crouch et al., 1989). Employee perception of drug testing
may play a likely role in increasing effectiveness of drug testing. If
drug testing is negatively viewed by employees (e.g., perceive it as
procedurally unfair), then as a result drug testing may negate
employment performance increasing turnover and absenteeism (Konovsky and
Cropanzano, 1991).

This analysis comes with limitations. Some individuals (active
military personnel, persons living in institutional group quarters such
as prisons and residential drug use treatment centers, homeless persons
not living in a shelter on the survey date) were excluded from the
survey and thus caution is necessary when generalizing our findings to
those who did not participate in the study. Our study design is
cross-sectional. We cannot determine the direction of causality between
misuse of PPRs and other variables assessed. Misuse of PPRs on the job
(or off the job) is an important research variable that may directly
influence employees' work performance, but our study did not
explore on-the-job prescription drug abuse or misuse. The survey did not
collect this information. Future study might look into the extent to
which on-the-job prescription drug misuse affects workplace performance.
Our study excluded other types of prescription drugs including
tranquilizers, stimulants, and sedatives. Thus, it is inappropriate to
interpret our findings for other types of prescription drug misuse.
Other relevant research questions that are unexplored in our study
include: (1) where employees obtain prescription drugs; (2) how they
misuse prescription drugs (e.g., abusing on the job or off the job); (3)
how and the extent to which misuse of prescription drugs affects other
workers or colleagues in the same organization and therefore negatively
affects competitive advantages of the firm; and (4) different
organizational and cultural factors that may be related to misuse of
prescription drugs.

Notwithstanding the aforementioned study limitations, our findings
are valuable in advancing the labor literature in the context of misuse
of prescription drugs. In summary, our findings suggest the association
between having problems associated with misuse of PPRs and absenteeism
and turnover in the American workforce. This may pose a potential threat
to many employers who are pressured to make their workplaces secure and
industrious. As portrayed in our study, drug policy plays a moderating
role for absenteeism and turnover in relation to having problems linked
to misuse of PPRs. Employers and practitioners must recognize this
prescription drug misuse problem among their employees and consider
introducing and developing best practices of workplace prescription drug
misuse prevention/treatment programs that should be available for every
employee. There is a general view that employees' misuse of alcohol
and illicit drugs lessens work performance and increase injury and
illness, but no such observation currently exists on employees'
prescription drug abuse or misuse.

Although there is a concern of privacy invasiveness (Tepper &
Braun, 1995; White, 2003), workplace drug testing has been considered as
a common practice to lessen addictive behaviors among employees. We
found the moderating effects of drug testing on the association between
absenteeism and having some problems linked to misuse of PPRs. This
finding offers an important practice implication that employers may
consider drug testing as another alternative in an effort to control
prescription drug misuse in the workforce. Along with the Employee
Assistance Programs (EAPs), drug testing has long been utilized in the
U.S. employment setting since the U.S. government delivered two major
regulations, the Drug-Free Workplace Act of 1988 and the Federal
Workplace Drug Testing Programs, to combat alcohol and illicit drug
misuse in the workforce. In 1997, about 49% of employees reported drug
testing in their workplaces (US DHHS, 1999). The literature provides
evidence that drug testing is effective and reduces alcohol and drug use
problems in the workforce (Bush & Autry, 2002; Carpenter, 2007;
Marini, 1991). In a recent national study, Carpenter (2007) found that
workplace drug testing significantly reduced marijuana use. Another
evidence of successful workplace drug prevention efforts comes from the
Federal Drug-free

Workplace Program (FDWP) (Bush & Autry, 2002) that includes the
following components: (1) written policy describing the employer's
expectations about drug use and consequences of policy violations; (2)
an employee assistance program (EAP) to provide confidential problem
assessment, counseling, referral to treatment, and follow-up support
after treatment; (3) supervisor training to orient supervisors to the
employer's drug abuse policy, to define the supervisor's
responsibility to refer employees when job performance deficits are
noted, and to recognize and respond to employees with problems; (4)
employee education to describe the signs and symptoms of drug abuse and
its effects on performance and to explain the program; and (5) drug
testing on a controlled and carefully monitored basis. Several sources,
based on the best practice case analysis in business, report that the
FDWP does work and is effective (Wickizer et al., 2004; ONDCP, 2010; US
DOL, 2010). In particular, Wickizer et al. (2004), who examined
workers' compensation claims data from the Washington State
Department of Labor and Industries, observed that the drug-free
workplace prevention intervention tool (similar to the FDWP concept)
successfully reduced employees' injury rates. Unfortunately,
however, most of the aforementioned studies and programs in relation to
drug policy/testing did not consider the extent to which employees may
suffer from misusing prescription drugs. More research effort is hence
needed to advance our understanding about efficiency and effectiveness
of drug policy/screening linked to misuse of prescription drugs in the
workforce and in the workplace. Importantly, more organized efforts in
practice including, among others, management commitment to recognizing
and monitoring seriousness of prescription drug misuse or abuse,
establishing a fair workplace drug policy/testing for misuse of
prescription drugs in a timely fashion, openly discussing prevention and
treatment alternatives, offering appropriate prevention/treatment
benefits to drug using employees, should be planned and implemented in
an effort to effectively respond to prescription drug problems among
employees.

Fenton, M.C., Keyes, K.M., Martins, S.S., Hasin, D.S. (2010). The
role of a prescription in anxiety medication use, abuse, and dependence.
American Journal of Psychiatry, August 4 (Epub ahead of Print).

French, M.T., Zarkin, G.A., Hartwell, T.D., Bray, J.W. (1995).
Prevalence and consequences of smoking, alcohol use, and illicit drug
use at five worksites Prevalence and consequences of smoking, alcohol
use, and illicit drug use at five worksites. Public Health Report, 110,
593-599.

Frone, M.R. (2006a). Prevalence and distribution of alcohol use and
impairment in the workplace: a U.S. national survey. Journal of Studies
on Alcohol and Drugs, 67, 147-56.

Frone, M.R. (2006b). Prevalence and distribution of illicit drug
use in the workforce and in the workplace: findings and implications
from a U.S. National Survey. Journal of Applied Psychology, 91, 856869.

Harwood, H., Fountain, D., Livermore, G. (1998). The economic costs
of alcohol and drug abuse in the U.S. 1992. Rockville, MD: National
Institute on Drug Abuse and National Institute on Alcohol Abuse and
Alcoholism.